Bullying: a growing workplace menace

Bullying in the workplace is emerging as a problem over the past decade. Despite the tendency for incidents of bullying to be underreported 2 it is widespread in all sectors of the workforce including healthcare in the United Kingdom (UK) 3. The culture of bullying in medicine contributes to this pattern of bullying behaviour that can adversely affect any aspect of working life from an employees health 4 to the reputation of the organisation 5. Therefore immediate changes are required to increase the recognition of this problem and take further steps to a solution.

Bullying and harassment

There are different ways to understand the terms bullying and harassment but considerable overlap exists with similar patterns of behaviour (figure 1).

Figure 1: Examples of bullying and harassment 6

Spreading malicious rumours, or insulting someone by word or behaviour (particularly on the grounds of age, race, sex, disability, sexual orientation and religion or belief)

Copying memos that are critical about someone to others who do not need to know

Ridiculing or demeaning someone picking on them or setting them up to fail

Exclusion or victimization

Unfair treatment

Overbearing supervision or other misuse of power or position

Unwelcome sexual advances touching, standing too close, the display of offensive materials, asking for sexual favours, making decisions on the basis of sexual advances being accepted or rejected

Making threats or comments about job security without foundation

Deliberately undermining a competent worker by overloading and constant criticism

The essential difference between bullying and harassment is that the latter is usually a single incident that relates to ones social identity and is therefore viewed as discriminatory in nature e.g. racial or sexual harassment. In legal terms harassment refers to a course of conduct directed at a specific person, which causes substantial emotional distress, and can be identified by equality laws in the relevant country.

On the other hand workplace bullying is generally not covered by specific legislation. The exception to this is found in such as Sweden and Norway 7. Indeed it is in Scandinavia where extensive research into bullying in the workplace originated 7.

Bullying

Bullying in the workplace is known internationally by terms such as mobbing, workplace harassment, employee abuse, mistreatment at work, and petty tyranny 8. There is no generally accepted definition of workplace bullying but it is summed up well by the following:

Persistent, offensive, abusive, intimidating or insulting behaviour, abuse of power or unfair penal sanctions which makes the recipient feel upset, threatened, humiliated or vulnerable, which undermines their self-confidence and which may cause them to suffer stress 9.

It is important to distinguish between bullying, which is always undermining and destructive, and constructive supervision that is developmental and supportive 8. The three essential elements of bullying are that it has a negative impact on the victim, it is persistent and, crucially, bullying is subjective 10. If a person feels bullied then he/she is being bullied 11. This last point may be controversial because it is dependent on the bullied persons views and not based on objective evidence. Nevertheless workplace bullying exists as a problem. According to the Chartered Institute of Personnel and Development (CIPD) there has been a shift of perception in organisations from denying it happens to accepting that bullying is a problem 3.

How common is bullying?

The Silent Epidemic 7

Workplace bullying affects up to 50 per cent of the UK workforce at some time in their working lives and has an annual prevalence nearly 40 per cent 7. One in 10 callers to the UK National Bullying Advice Helpline are health care professionals 3. A questionnaire survey 12 revealed that 38% of staff in a community healthcare trust were subject to workplace bullying in the previous year and that 42% had witnessed bullying of others. The British Medical Association (BMA) has acknowledged that bullying rates are higher in healthcare organisations and stated that 1 in 7 National Health Service (NHS) staff reported being bullied by other staff 13.

The scale of the problem has been widely highlighted as a problem in the nursing profession 10 with increased rates of bullying reported in Black and Minority Ethnic (BME) groups 14. In doctors bullying may occur in the clinical, educational 8 and research environment 15. One survey of doctors in the UK revealed that 37% of junior doctors had been bullied and 84% had experienced at least one bullying behaviour in the preceding year16. Higher rates have been reported in non-European Union (non-EU) doctors practicing in westernised countries 17 who are also less likely to take action against bullying 18.

Despite the growth of literature in this area the problem of workplace bullying is obscured by underreporting which has numerous causes (figure 2).

Figure 2: Reasons for underreporting of bullying 2

Fear it will make matters worse

The belief that nothing would be done about it

Concerns about confidentiality

Fear of possible victimisation

Concerns of being labelled a troublemaker

May be seen as an admission of failure

A degree of learned tolerance that may imply that the behaviour is acceptable

The greatest fear is that of reprisals from the employer, associates of the bully, and powerful professionals, who may close ranks and compromise the career of the whistle blower 1.

Why do people bully in medicine?

The antecedents to bullying have undergone considerable debate in the psychology literature. Bullies may be attracted to the caring professions to take advantage of the vulnerability embedded in them in relation to clients and employees 1. However in most cases the bullying in medicine is likely to be unintentional and could be shaped by the power inequality in relationships (e.g. consultant Vs junior doctor) in the field.

Moreover the traditional hierarchy within medicine and the teaching by intimidation and humiliation may foster a culture of bullying 18. Studies in the United States 19 and UK 13 have suggested that bullying commences with medical student and that this sets up a transgenerational legacy 7 as the behaviours of bullying are passed down. The BMA urges for a stop to the cycle of bullying and argue further that the target ethos in the health service with the survival of the fittest culture adds to bullying 13.

How do you know if you are being bullied?

If you are being bullied early warning signs may be present. These include the perception that your working relationship is different, that you are being persistently got at, that your work is being unfairly criticised, or you begin to question whether these mistakes you are supposed to have made really are your fault 20. In addition to feelings of being undermined, or humiliated, bullying may also be associated with symptoms (figure 3).

Figure 3: Symptoms of bullying 20

Physical

Emotional

Sleeplessness

Acute anxiety

Nausea

Feeling isolated

Migraine/severe headaches

Loss of confidence/self-esteem

Palpitations

Depression

Skin complaints

Panic attacks

Sweating/shaking

Anger

Stomach problems

Mood swings

Backache

Lack of motivation

Loss of appetite

Suicidal thoughts

Lethargy

Why does bullying matter?

It is clear from the physical and psychological effects that bullying affects people in their personal health. Workplace bullying can also contribute to problems of staff retention and economy. Estimates suggest that in the UK bullying cost employers 80milion lost working days and up to 2-30 billion in lost revenue each year 7. It costs the NHS more than 325 million a year and accounts for around 50 per cent of stress-related workplace illnesses 5.

Other effects of bullying at work include poor morale, poor employee relations, loss of respect for managers or supervisors, poor performance, lost productivity, absences, resignations, damage to organisations reputation and potential costs in tribunal and other court cases 6. Ultimately if the culture of bullying results in demoralized staff working, in a caring profession, it is the patients who will suffer.

What is currently being done about it?

In the UK the BMA has called for zero tolerance on bullying 13 and have provided a report on bullying and harassment in the workplace 21. Most NHS trusts disseminate anti-bullying policies, in connection with Dignity at Work, but the effective implementation of these policies has been questioned with the criticism that it is only for show 18. The information on guidance and policy, in relation to workplace bullying, is not widely publicised and the question is whether bullying is being systematically played down?

Recommendations

Although organisations such as the health service have taken steps to deal with bullying it is clear that problems persist. Heenan 5 states that an all-singing all-dancing policy is worthless without a culture that believes in and supports it and recommends steps employers need to consider (figure 4).

Figure 4: Key steps recommended for employers 5

Look at the culture of the organisation where and how might the risk of harassment arise?

Foster an environment where staff feel able readily to raise any concerns, before they become problems.

To support this, have a clear and well publicised policy to tackle harassment issues.

Back this up with training (including how to handle grievances) and set good examples through role models.

Deal with harassment wherever and however it arises, to demonstrate that it is unacceptable and will not be tolerated.

Provide independent employee assistance, including confidential counselling and other support for employees to enable to challenge unreasonable behaviour which, left unchecked, could lead to harassment.

Figure 5: What to do if you are being bullied 2

Steps to take

Options for support

Approach, or write to, the bully and ask them to stop

Speak to a friend, colleague, supervisor or manager

Ask line manager, supervisor, human resource representative or trade union official to speak to the bully.

Ask employer for support from a specially trained staff member

Keep a record of any incidents and informal action taken

Speak to general practitioner especially if your health is affected

Consider a formal complaint in writing to their line manager or human resources representative

Seek counselling which has been provided by the NHS to its entire staff since 2000

Have a colleague accompany you to any formal investigation meetings

Contact bullying and harassment hotlines

Formal investigation may recommend a disciplinary hearing

Employer may refer you to an external agency for more support

Alternative management action may be considered e.g. facilitated discussion or redeployment

Mediation may be on offer to encourage and help reach an informal outcome

Awareness of bullying needs to be raised and the problem dealt with at an organisational and individual level. The authors suggest that bullying should be incorporated into teaching programmes and induction of junior doctors. Heenan 5 recommends training for managers and supervisors so that they have the confidence to deal with a situation, and deal with it at an early stage, rather then allowing the problem to accumulate and end up in the courts. Therefore it is in the healthcare trusts interests to take these steps to monitor and manage this problem.

In addition employees in healthcare need to be better informed of what steps to take if they find themselves as victims of a bully at work. NHS employers provide options available to deal with bullying and provide support for it (figure 5).

Conclusion

The late Tim Field, founder of the National Workplace Bullying Helpline, warns that everyone is at risk of becoming a target of bullying 1. However the bully in healthcare organisations may not often realise what they are doing, so do both parties require help? There are conflicting views for the solution to bullying in the workplace regarding whether educational 22 or punitive 17 measures are appropriate. This will continue to be a matter of debate. Whichever approach is adopted, identification and increased awareness of bullying is the first step to the solution.

Bullying is an old problem that keeps re-emerging without a clear solution 3

KEY POINTS

Bullying is subjective if you feel bullied then you are bullied

Bullying is more prevalent then we think because of underreporting

Causes of bullying are complex and may be embedded in the culture of the organization

Being bullied is associated with emotional and physical symptoms

Bullying has implications at a personal, social, and organisational level

Implementation of policies by health care trusts need to be improved

Organisations need to be more proactive in raising awareness of this growing menace and demonstrate that it is unacceptable

13. BMA Newswire article. BMA calls for zero tolerance on bullying and harassment in the Workplace. 19 May 2006.

14. Giga S, Hoel H, and Lewis D. A review of Black and Minority Ethnic (BME) employee experiences of workplace bullying. University of Bradford, (Research commissioned by the Dignity at Work Partnership). May 2008.